Readiness Assessment Tool RAT Final

1

`

EHW MANAGEMENT SYSTEMS

MONITORING AND READINESS ASSESSMENT TOOL

FOR THE PUBLIC SERVICE

ANNEXURE (E)

OCTOBER 2010

2

TABLE OF CONTENT

SECTION NO CONTENT PAGE NO

DEFINITIONS 3

ACRONYMS AND ABBREVIATIONS 5

1 INTRODUCTION 7

1.1 PURPOSE, OBJECTIVES AND EXPECTED OUTCOMES

8

1.2 GENERIC ELEMENTS OF AN EFFECTIVE EH&W MANAGEMENT SYSTEM

9

1.3 SIGNIFICANCE OF THE ELEMENTS ON POLICY IMPLEMENTATION

9

2 INSTRUCTIONS ON HOW TO COMPLETE THE EH&W MANAGEMENT SYSTEM READINESS ASSESSMENT TOOL

12

3 THE ACTUAL ASSESSMENT PROCESS

14

3.1. TABLE 1: THE RATING SCALE 14

3.2. TABLE 2: ELEMENTS, CRITERIA AND SCORES

15

3.3. TABLE 3: ASSESSMENT SCORES PER ELEMENT AND FORMULA

38

3.4. TABLE 4: GRAPHICAL PRESENTATION OF SCORES PER ELEMENT

39

3.5. TABLE 5: RECOMMENDED ACTIONS FOR OVERALL ASSESSMENT OF LEVEL OF READINESS

40

4. TABLE: 6 ACTION PLAN FOR IDENTIFIED GAPS

41

3

DEFINITIONS

Situational Analysis

Systematic collection and evaluation of past and present economical, political, social and technological data. It is aimed at:

• Identification of internal and external forces that may influence the organization’s performance and choice of strategies, and

• Assessment of the organization’s current and future strengths, weaknesses, and opportunities.

Integrated needs analysis

(Also called needs assessment.)

Technique for determining the steps to be taken in moving from a current state to a desired future-state. It begins with:

• Listing of characteristic factors (such as attributes, competencies, performance levels) of the present situation (“what is”),

• Cross-lists factors required to achieve the future objectives (“what should be”), and then

• Highlights the ‘gaps’ that exist and need to be ‘filled’.

Impact assessment (IA)

"a process aimed at structuring and supporting the development of policies. It identifies and

assesses the problem at stake and the objectives pursued. It identifies the main options for

achieving the objective and analyses their likely impacts in the economic, environmental

and social fields. It outlines advantages and disadvantages of each option and examines

possible synergies and trade-offs".

Standard Operating Procedure a document which describes the regularly recurring operations relevant to the quality of the

investigation. The purpose of a SOP is to carry out the operations correctly and always in

the same manner. A SOP should be available at the place where the work is done".

4

Ill-health determinants include the range of personal, social, economic and environmental factors which determine

the health status of individuals or populations. The factors which influence health are

multiple and interactive. They are related to the actions of individuals, such as health

behaviors and lifestyles, but also factors such as income and social status, education,

employment and working conditions, access to appropriate health services, and the

physical environments.

Operational controls are developed and implemented to ensure that potential for significant negative environmental impacts are minimized

Pillar refers to the four functional pillars of the EHW strategic framework. They are:

• HIV&AIDS and TB Management

• Health and Productivity Management

• SHERQ Management

• Wellness Management

Integrated Health Risk Assessment

a systematic procedure to identify potential health hazards, evaluate the extend of

exposure subjectively and/or objectively, and to establish the need for, and effectiveness of

existing control measures. (Schoeman, 1994:7). Furthermore it facilitates the drafting of

occupational exposure monitoring, medical surveillance and occupational health education

programs. (Goede 1998; Van Der Merwe 1998:14)

5

ACRONYMS AND ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

COID Compensation for Occupational Injuries and Diseases

EHW Employee Health and Wellness

GEMS Government Employee Pension Fund

HCT HIV Counseling and Testing

HIV Human Immunodeficiency Virus

HOD Head of Department

HR Human Resource(s)

HPM Health and Productivity Management

IAA Inspection Approved Authority

IEC Information, Education and Communication

IHRA Integrated Health Risk Assessment

M&E Monitoring and Evaluation

OHS ACT Occupational Health and Safety Act

PEP Post-exposure prophylaxes

PLHIV People living with HIV

SHERQ Safety, Health, Environment, Risk and Quality

6

SOP Standard Operating Procedure

STI Sexually Transmitted Infection

TB Tuberculosis

TOR Terms of Reference

7

1. INTRODUCTION

DPSA has developed several policy documents in 2007/8 for EHW in the Public Service to coordinate the programmes and services that are offered

in a unified manner. These documents are the following:

• EHW Strategic Framework

• EHW Policies:

o HIV and AIDS & TB Management

o Health and Productivity Management

o SHERQ Management (Safety, Health, Environment, Risk, and Quality)

o Wellness Management

• The following tools:

o Policy Generic Implementation Guides

o Step-by-Step System Implementation Guides

o Systems Monitoring / Readiness Assessment Tool

The intention with this EHW Management Systems Monitoring / Readiness Assessment Tool is to provide a framework within which Government

Departments can develop and maintain an EHW Management System. It is based on the AMS management system standard (AMS 16001: 2003).

This EHW Management System Monitoring / Readiness Assessment Tool has been developed to be compatible with the ISO 9001:2000 and the

ISO 14001:1996 management systems standards as well as the OHSAS 18001:1999, in order to facilitate the integration of quality, environmental

and occupational health and safety management systems of department, should they wish to do so. This Monitoring Tool will be reviewed or

8

amended when considered appropriate. Reviews will be conducted when new editions of AMS 16001, ISO 9001, ISO 14001 or OHSAS 18001 are

published, to ensure continuing compatibility.

1.1. PURPOSE, OBJECTIVES AND EXPECTED OUTCOMES

1.1.1. PURPOSE

The purpose of the organizational readiness assessment is to enable departmental officials in EHW to conduct a self-assessment of their readiness

to implement the EHW policies for the Public Service. The readiness assessment explores many aspects of organizational performance in respect

to EHW, and provides EHW officials with the opportunity to reflect on their state of readiness to implement the four EHW policies. The Systems

Monitoring / Readiness Assessment Tool should be used for this readiness assessment. EHW coordinators and managers should use these

guidelines to conduct the readiness assessment.

The requirements in this Systems Monitoring / Readiness Assessment Tool establish departments ‘readiness to operationalise the four pillars of the

EHW Strategic Framework as expressed through the four EHW policies (HIV&AIDS and TB Management, Health and Productivity Management,

SHERQ and Wellness Management).

The tool will further establish the basic commitment of every department to document and sustain an EHW Management system. The system must

include a clearly mapped out departmental structure and documentation covering planning activities, responsibilities, practices, procedures and

processes for achieving the requirements of the EHW Management system. Resources must also be provided for developing, implementing,

achieving, reviewing and maintaining the EHW Management policies.

1.1.2. OBJECTIVES OF THE READINESS ASSESSMENT TOOL IS FOR:

• Assessment of organizational readiness and implementation proficiency

• Identification of gaps in capacity to implement EHW initiatives

• Promotion of discussion on many aspects of organizational readiness for implementation as a means of fostering shared understanding

9

• Helping to nurture commitment among stakeholders regarding the implementation of EHW Policies

1.1.3. EXPECTED OUTCOMES FROM THE READINESS ASSESSMENT ARE:

• Assessment scores on 5 aspects of organizational readiness

• More in-depth understanding about the basic requirements for a successful system for the implementation of EHW initiatives

• Readiness Action Plan

1.2. GENERIC ELEMENTS OF AN EFFECTIVE EHW MANAGEMENT SYSTEM

For departments to establish an effective EHW Management System they should have the following five elements contained within the AMS

16001, ISO 9001, ISO 14001 or OHSAS 18001 standards and guidelines. These elements are:

• Commitment to EHW Management policies

• Planning of the EHW Management system

• Implementation and operation of the EHW Management system

• EHW Management system evaluation, corrective and preventive action

• EHW Management review

1.3. SIGNIFICANCE OF THE GENERIC ELEMENTS ON THE EHW POLICY IMPLEMENTATION

1.3.1. Commitment to EHW Management policies

The elements intention is to ensure ongoing commitment to EHW management system by establishing an appropriate EHW Management

Strategy, Plan and Policies which address all four pillars of the EHW Strategic Framework 2008.

10

The EHW management strategy should be determined by Senior Management, and be informed by relevant evidence of needs and risk

assessments conducted (initial review).

The ideal for realization of this element would be for departments to develop departmental strategic plans that reflects Employee Health and

Wellness as one of its inherent priorities, and commitment to address such priorities through policy measures and principles outlined in the four

EHW policies (HIV&AIDS and TB, HPM, SHERQ and Wellness Management)

The EHW policies act as the foundation for the entire EH&W management system. Therefore, the structure of the system should be designed to

deliver the strategy of the Department. The policy should be a documented statement of how the organization is committed to reduce the impact

of Workplace-based ill- health and incidents on its employees, their families and the Department, prevention of ill-health, legislative

compliance, continual improvement and organization sustainability.

1.3.2. Planning of EHW Management System

Realization of this element allows departments to identify, evaluate and understand how it and its clients impinge on the wellness of the work

force and their families. The element is intended to guide the organization on how to identify and assess risks and hazards through a dynamic,

formal, structured and holistic process to facilitate effective risk reduction plans and actions.

Planning of the EHW Management System should seek to facilitate compliance with applicable legislative and regulatory frameworks as well as

to identify and assess EHW Management Objectives and Targets. Clearly documented Standard Operating Procedures (SOP”S) for assessment

of Ill-health determinants and related impact and significant risks, as well as SOP’s for identification of applicable legislative and regulatory

requirements/standards should guide implementation of this element in the organization.

The element will be verified by availability of a mainstreamed, costed EHW operational plan which specifies strategic objectives and targets to

address strategic EHW issues as well as specific activities and time frames to attain set objectives. Financial and operational controls should be

specified in the plan, as well as mechanisms for tracking and measurements for attainment of set objectives and EHW management systems

11

outcomes.

1.3.3. Implementation and operation of EHW Management System

This element refers to the department’s obligations to develop capabilities and support mechanisms necessary to achieve its EHW Management

policies, objectives and targets. The organization should identify and provide the appropriate specialized human and technological skills, and

financial resources to implement the EHW Management system.

A Mainstreamed and costed operational plan should be developed to reflect key structures and responsibilities (champions and subordinates),

activities for organizational support and capacity development with clearly defined objectives and targets for the EHW Management system.

Clear communication strategy, document control, system control and emergency preparedness are key components of this element.

1.3.4. EHW Management System Evaluation and Corrective Action

This element refers to monitoring and measurement of the EHW Management System efficiency and effectiveness with focus on documentation

and analysis of indicators for incidents rate, non-conformance and corrective actions, reports, effects and outcomes of workplace education, as well

as EHW Management system audits.

EHW indicators and reporting system will be informed by, among others, the Policy Implementation Guides, HIV Counseling and Testing (HCT)

campaign and the Government Sector M&E Plan for HIV&AIDS response.

1.3.5. EHW Management System Review

Departments need to review and continually improve the EHW management system in line with findings of the overall quarterly / annual

departmental self assessment using this tool.

12

2. INSTRUCTIONS ON HOW TO COMPLETE THE TOOL

2.1. Description of the Tool Components

ELEMENT

The standard that should be maintained and monitored

CRITERIA

The measures that are used to judge performance

MEANS OF VERIFICATION

Evidence that the criteria is met

YES / NO

Tick yes when system is in place and cross no when not

NUMBER OF AWARDS

Awards for all elements on the rating scale 1-4

13

2.2. Steps

Step 1 Read all the statements in the EHW Management Systems

Monitoring/ Readiness Assessment Tool (Table 2) and decide which

of the statements are true for your department by placing a

checkmark (√) in the box marked “yes”. Or If not then x “No”

Step 2 Refer to the Rating scale (Table 1) for allocation of awards for each

Criteria in the Status/Results Column

Step 3 Add the awards for each Element and enter the total score into

Table 3 by using the provided formula. Please note the title provided

for each of the columns by looking at the category letters (A-E) and

the associated component of organizational readiness

Step 4 Please refer to Graphic Presentation of Scores Per Element

(Table 4) and transfer your scores to the graph and shade your

scores. Note the extent to which your department could be

assessed as ready to implement.

Step 5 Analyze your overall assessment score and determine the level of

readiness to implement in your organization in each area of

assessment (Table 5).

Step 6 Complete the Readiness Action Plan for your department based on

identified gaps, to implement and monitor (Table 6 )

14

3. THE ACTUAL ASSESSMENT PROCESS:

Name of the Organization/Department ……………………………………………

Date of review………………………………………………………………………...

Responsible Person………………………………………………………………….

3.1. READINESS RATING SCALE:

SCORE /AWARD DESCRIPTION OF THE READINESS LEVEL

1 Evidence of draft, with no evidence of approval, implementation or monitoring and evaluation

2 Evidence of approval, with no evidence of implementation, or monitoring and evaluation

3 Evidence of approval and implementation, but no evidence of monitoring and evaluation

4 Evidence of approval, implementation and monitoring and evaluation

Shaded blocks The shaded blocks should not be scored as the descriptions in the criteria indicate headings

15

TABLE 2: ASSESSMENT TABLE WITH ELEMENTS, CRITERIA, MEANS OF VERIFICATION AND ALTERNATIVE RESPONSES (Y=Yes; N=No)

1. COMMITMENT, INITIAL REVIEW AND EHW MANAGEMENT POLICIES

SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

1.1 COMMITMENT INTENT: Ensure ongoing Commitment to the EHW Management system by establishing an Appropriate EHW Management strategy, plan and policies to address EHW issues

1.1.1 Departmental Strategy developed

Documented Departmental Strategy

1.1.1.1. Departmental Strategy addresses the following:

• HIV&AIDS and TB

• HPM

• Wellness

• SHERQ

Documented Departmental Strategy

1.1.2.EHW Policies developed

Documented EHW Policies

SUB-TOTAL (6 X 4 CRITERIA = 24)

16


SCORE/AWARDS

ELEMENT

CRITERIA


Y

N

1

2

3

4

COMMENTS

1.1.2.1.EHW Policies integrate the management of the following:

• HIV&AIDS and TB

• HPM

• Wellness

• SHERQ

Documented EHW Policies

1.1.3 Costed EHW Operational plan developed

EHW costed Operational Plan

1.1.3.1. EHW Operational Plan incorporates activities to realize policy measures and principles to manage the following workplace issues:

• HIV&AIDS and TB

• HPM

• Wellness

1.1.COMMITMENT …continued

• SHERQ

4 Distinctive KRA’s in Operational Plan that address all 4 pillars

SUBTOTAL (9 X 4 CRITERIA = 36)

17


SCORE/AWARDS

ELEMENT

CRITERIA


Y

N

1

2

3

4

COMMENTS

1.2.1 Departmental situational analysis for EHW policies conducted

Report on situational analysis

1.2.1.1. Situational analysis incorporated the following:

• Integrated health risks assessment in the department

IHRA Report

• Integrated needs analysis of all 4 pillars

HIV&AIDS and TB

HPM

Wellness

1.2 INITIAL REVIEW (COLLECTION OF BACKGROUND INFORMATION)

INTENT: To determine the current position of the Department with regard to EHW issues

SHERQ

Integrated needs analysis report

SUBTOTAL (6 X 4 CRITERIA = 24)

TOTAL: HIGHEST SCORE 21 x 4 CRITERIA = 84 (maximum rating)

18

2. PLANNING OF EHW MANAGEMENT SYSTEM

SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

2.1.1.Documented standard operating procedure (SOP) for:

SOP on ill-health determinants

• ongoing identification of Ill-health determinants of the department

SOP on ill-health determinants

• Impact assessment

SOP on Impact assessment

2.1 ILL-HEALTH DETERMINANTS, THE IMPACT AND EVALUATION OF HEALTH RELATED RISKS

INTENT: Identify and assess EHW risks through a dynamic, formal, structured and holistic process to facilitate effective risk reduction plans and actions

• Evaluation of significant

risks

SOP on Evaluation

SUB-TOTAL (3 X 4 = 12)

19


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

2.2.1.Developed Specific Operating Procedure(s) for:

• Identification of applicable current legal and regulatory requirements

SOP(s) for legal and regulatory requirements

2.2 LEGAL AND OTHER REQUIREMENTS

INTENT: Facilitate compliance with applicable legislation and regulatory requirements

• identification of legal and regulatory compliance

SOP(s) for legal and regulatory compliance

2.3 EHW MANAGEMENT SYSTEM OBJECTIVES AND TARGETS INTENT: Identify and Assess EHW management objectives and targets.

2.3.1. Documented Departmental EHW Management objectives and targets aligned to the Departmental Strategic Plan

Departmental Strategic Plan


20


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

2.3.2 EHW Operational controls and management plans developed for the following pillars:

• HIV & AIDS and TB HIV & AIDS and TB operational control plan

• HPM

HPM operational control plan

• Wellness

Wellness operational control plan

2.4 EHW MANAGEMENT SYSTEM PLAN(S)

INTENT: Establish objectives and targets and achieve them in a specified time frame.

• SHERQ

SHERQ operational control plan



21

3. IMPLEMENTATION, OPERATIONAL CONTROLS AND MANAGEMENT OF EHW MANAGEMENT SYSTEM

SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.1 STRUCTURE, RESPONSIBILITY AND ACCOUNTABILITY FOR EHW MANAGEMENT SYSTEM

INTENT: Identify and provide the appropriate specialized human skills, technological and financial resources to implement the Department’s EHW management system.

3.1.1 The Departmental structure makes provision for an EHW unit

Documented Departmental Structure

3.1.2 Sufficient human resources with relevant skills and technical resources provided for:

Documented Departmental structure with relevant EH&W profiles


• HPM

• Wellness

• SHERQ


-

22


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.1.3.Sufficient financial resources provided for EHW

Departmental Budget

3.1.4.Appointment of EHW SMS with defined roles, responsibilities and authority

Departmental structure

3.1.5. Clear roles & responsibilities for EHW staff defined

EHW Policies

3.2.1. EHW Committee representatives are from all levels of the Department

Signed Submission Signed letters of appointment by the HOD

3.2.2. Employee / labour organizations form part of the committee

Signed Submission Signed letters of appointment by the HOD

3.2.3.Roles & responsibilities of the committee are defined and documented

Terms of reference (TOR)

3.2 EHW MANAGEMENT COMMITTEES INTENT: EHW Management Committees established and operating effectively to comply with policy.

3.2.4. Committee meetings used to review EHW programmes/policies

Minutes of the committee meetings

SUB-TOTAL (7 x 4 = 28)

23


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.3.1.EHW Information and awareness programmes are developed and implemented

EHW Communication Strategy

3.3.1.1.Awareness programme is relevant to prevalent risks / impact relating to:

• HIV&AIDS and TB

• HPM

• Wellness

• SHERQ

EHW Operational Plan

3.3.1.2. Information customized to relevant language and literacy levels of target groups

IEC Materials language and format (visuals)

3.3.1.3. EHW programmes that include diversity management.

EHW Operational Plan

3.3 EHW MANAGEMENT INFORMATION, AWARENESS, EDUCATION AND COMPETENCE

INTENT: To provide correct and up-to-date information on EHW and workplace issues, and to empower employees with skills to help them to adopt behaviours that will reduce ill-health and occupational hazards.

3.3.1.4.EHW programmes integrated into existing HR policies and programmes

Documented induction programmes


24


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.3.3. Competency is determined through the Performance Management System at all levels of EHW management

Performance management reviews

3.3.3.1 All role players are appropriately capacitated in line with Departmental standards and procedures

Capacity building records

3.3.3.2.EHW policies are accessible to all employees

EHW Communication Strategy

3.3.3.3.Capacity building programme monitored

M&E Reports

3.4.1. System for internal communication is established

SOP for internal communication EHW Newsletters and bulletins

3.4.2. System for external communication is established

SOP for external communication Record of response from relevant stakeholders

3.4.3.System for EH&W Annual Reporting

Departments annual report which includes EHW

3.4 EHW MANAGEMENT SYSTEM COMMUNICATION INTENT: Share EHW information with interested and affected parties

3.4.4. System Performance communicated

Departments annual report which includes EHW


25


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.5 DOCUMENTATION AND DOCUMENT CONTROL INTENT: Establish and maintain procedures for controlling all documents and data required by the Department.

3.5.1. Documentation system is in place and documents are kept for a minimum period of 10 years

SOP for document control

3.5.2. Documents readily identifiable


3.5.3. Reports suitably archived and safeguarded


3.6.1. Procedures and criteria established to prevent deviation from policy, objectives and targets for:

• HIV&AIDS and TB

• HPM

• Wellness

3.6 OPERATIONAL CONTROLS AND MANAGEMENT OF EHW MANAGEMENT SYSTEM

INTENT: Ensure that Control measures are prepared and implemented to maintain and improve the EHW Management system Performance in accordance with policy requirements

• SHERQ

SOP for policy compliance


26


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.6.1.1. HIV&AIDS and TB Controls: i) Procedures and criteria established to prevent deviation from HIV&AIDS and TB Policy, objectives and targets

ii) Procedure includes operational criteria for:

• Management of employees with HIV&AIDS and their families

• HIV Testing in the workplace

• Universal precautions and infection control

• Discrimination

• Compensation

Relevant SOP

• Working hours and reasonable accommodation

Departmental guidelines on working hours


27


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

iii) Documented procedures to reduce the rate of HIV&AIDS,STI and TB transmission from infected to uninfected employees and their families

Infection control policy

iv) Procedures to increase roll-out of workplace prevention programmes which includes:

• Condom distribution

• STI diagnosis and management

• TB screening and prophylaxis

Documented workplace programme

v) Documented procedure to minimize the risk of HIV and TB transmission resulting from occupational exposure to blood and blood products.

Policy for PEP


28


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

vi) Creation of enabling environment for workplace HIV Testing focusing on:

• Routine counseling and testing for individuals at high risk (transport, farmers, etc.)

Workplace Counseling and Testing policy/ SOP

• Peer education programme

Documented peer education programme

vii)Procedure for treatment, care and support of PLHIV and their families to enable them to live healthy and productive lives

Treatment care and support SOP

viii),Promotion of Human rights and access to justice:

• Stigma mitigation

• Anti-discriminatory work-practices

Legal & Human rights SOP

ix)Procedures for suppliers, contractor and contracts control are in place

• Risk liability identified and managed

HIV&AIDS and TB management SOP for suppliers and contractors


29


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

x) Promotion of research, monitoring and surveillance in place:

• Appropriate HIV&AIDS and TB management indicators monitored and reported

Documented reports on HIV&AIDS and TB Management indicators


TOTAL FOR HIV&AIDS AND TB 20 X 4 = 80

30


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.6.1.2 HPM Controls: i) Absenteeism rate is

monitored quarterly and feedback reports are provided to management

HR Records

ii) Awareness, education and prevention programmes on chronic disease management are in place

Documented Education Programme

iii) All employees have access to treatment, care and support for chronic disease management

GEMS report Documented EHW Programmes on treatment, care and support

iv) Confidentiality code of conduct is maintained

Signed Confidentiality Code of conduct

TOTAL FOR HPM (4 X 4 = 16)

31


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.6.1.3 Documented Wellness Management controls: i) Wellness Facilities are available (E.g. Wellness Centre, Gym, Canteen)

Site visit report

ii) Awareness and Education Programs on Wellness are in place.

Operational Plan

iii) Systems for dissemination of wellness information are in place (Electronic or hard copy)

Communication Strategy

iv) Counseling Services are in place.

Analysis Report

v) Organisational Development and Support Programmes (harassment, discrimination, victimization, workplace violence and bullying) are in place

Operational Plan

vi) Flexible policies that address work-life balance are in place.

Departmental Policies

vii) Child care facilities in the Workplaces are in place.

Site visit report

viii) Retirement programmes are implemented.

M&E Report

Ix) Mainstreaming of HIV and AIDS, gender, disability, and youth development into the Workplace is supported.

Departmental Strategy

TOTAL FOR WELLNESS MANAGEMENT 9 X 4 = 36

32


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

3.6.1.4. SHERQ controls i) Identify and manage

occupational health and safety related risks

Health Risk Report

ii) Environmental hazards identified, assessed and controlled

Health Risk Report

iii) All OHS ACT statutory appointments are made

SOP for regulatory requirements and compliance Signed appointment letters

iv) Well maintained buildings and offices

SOP for buildings and offices

v) Waste safely disposed

SOP for waste disposal

vi) Good housekeeping maintained and practiced

SOP for house keeping

vii) Well maintained machinery and electrical equipment

SOP for maintenance

viii) OHS audits conducted

Audit report

ix) Disaster management plans developed, implemented and maintained

SOP for disaster management

x) Risk assessment controls monitored and evaluated

M&E report

xi) Risk assessment reports verified by approved IAA’s

Risk assessment reports

TOTAL FOR SHERQ 11 X 4 = 44

33


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

The following procedures detailing the potential for and response to traumatic events:

Trauma debriefing for rape victims implemented and maintained

Emergency Response Plan

3.7 EMERGENCY RESPONSE AND CONTROL OF THE EH&W MANAGEMENT SYSTEM

INTENT: Provide Adequately equipped and trained emergency response to accidental and uncontrolled events

Emergency preparedness and response plans and procedures

Emergency Response Plan


34

4. EHW MANAGEMENT SYSTEM EVALUATION, CORRECTIVE AND PREVENTIVE ACTION

SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

4.1.1.The impact of EHW Management in the workplace is monitored and evaluated by:

maintaining records on sickness and identifying root causes thereof

• maintaining records on absence and identifying root causes thereof.

• tracking performance of key indicators

• meeting of objectives and targets

Sick leave records Monthly & quarterly reports EH&W Records M&E Plan

4.1.2.Reports are forwarded to Senior management on:


• HPM

• Wellness management

• SHERQ management

M&E Reports

4.1 EHW MANAGEMENT SYSTEM MONITORING AND MEASUREMENT

INTENT: Development of a corporate memory of EHW to facilitate effective communication internally and externally and changing people’s behaviour with regard to EHW

4.1.3. Senior Management takes action on the reported findings and recommendations and provides feedback

Senior Management Feedback Report


35


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

4.2.1. System established to identify non-conformances and incidents in the EHW Management system.

Corrective and Preventive Action Plan

4.2 EHW MANAGEMENT SYSTEM, INCIDENTS, NON-CONFORMANCES, CORRECTIVE AND PREVENTIVE ACTION

INTENT: Prevent non-conformances of the EHW Management system requirements such as policy and standards

4.2.2. Documented Procedures that cover responsibilities for carrying out corrective and preventive actions

SOP on corrective actions

4.3.1. Procedures ensuring the identification, maintenance and disposal of EHW records available

SOP on Record Management

4.3 EHW MANAGEMENT SYSTEM RECORDS INTENT: To establish and maintain procedures for the identification, maintenance and distribution of EHW related records

4.3.2. Records are legible, Identifiable, traceable, protected, retained, confidential and auditable

Individual case files COID files Case registers Sample records


36


SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

4.4.1. Annual systems audit carried out to determine if the requirement for the EHW Management system has been met.

EHW Management System Audit Report

4.4.2. The department’s objectives and targets are being met as determined

Audit Report

4.4 EHW MANAGEMENT SYSTEM AUDIT INTENT: Review and continuously improve the management, compliance and effectiveness of the programme.

4.4.3. Previous audit results and non-conformances reviewed and closed

Corrective Action Plan



37

5. EHW MANAGEMENT SYSTEM REVIEW

SCORE/AWARDS

ELEMENT

CRITERIA

MEANS OF

VERIFICATION

Y

N

1

2

3

4

COMMENTS

5.1.1. Full EHW Management performance reviewed by Senior Management.

5.1.2. Senior Management has taken action for any recommendations for system changes.

5.1.3. EHW Management system review considers statistics, audit results, and other performance indicators.

5.1.4. Other relevant parties provided with access to results of review.

5.1.5.Policy reviewed to reflect changing conditions and information

5.1.6.Review frequency identified and documented

5.1 EHW MANAGEMENT SYSTEM REVIEW INTENT: Ensure sustainable and continuous improvement and effectiveness.

5.1.7. Sustainability performance indicators related to EHW Management identified and documented.

EHW Management System Review Report


38

TABLE 3: RECORD OF ASSESSMENT SCORES PER ELEMENT

CATEGORY

ELEMENT

HIGHEST SCORE

YOUR SCORE

YOUR AWARD

A Commitment to EHW Management policies

B Planning of the EHW Management system

C Implementation and operation of the EHW Management system

D EHW Management system evaluation, corrective and preventive action

E EHW Management review

TOTAL

Formula for calculation: - Your score is the total number of awards you allocated per element (33) - Highest score is the highest number of awards you can allocate (76)

- Your overall award is (2), i.e. 33 (Your Score) x 4 = 2

76 (Highest Score)

39

TABLE 4: GRAPHICAL PRESENTATION OF ASSEMENT SCORES PER ELEMENT

4

3

2

1

0

A B C D E

Elements of Readiness

Levels of Readine

ss (A

wards)

40

TABLE 5:- RECOMMENDED ACTIONS FOR OVERALL ASSEMENT OF LEVEL OF READINESS

SCORE ACHIEVED

OVERALL ASSESSMENT OF

LEVEL OF READINESS TO IMPLEMENT

1

Scores in this category are assessed as a very low level of readiness in the area for which the score was derived. Careful assessment must be made as to the extent to which more capacity is needed in this area to implement particular provisions of the EHWS. If this area can have an effect, it will be advisable to develop capacity in this area before adoption of initiatives which may be affected. This must be reflected in your implementation plan.

2

This is assessed as a low level of readiness. If this area has the potential of affecting initiatives to be undertaken, it will also be prudent to apply corrective measures in order to develop capacity. The initiative may not fail as a result of this level of readiness, but there will be significant difficulties during implementation. If scores fall into this category, your department is not quite ready.

3

Scores in this category are assessed as average. Here, initiatives which may be affected can be undertaken, but efforts must be made to address weaknesses and threats in one’s implementation plan. Potential constraints could be mediated through careful planning.

4

This score is assessed as a high level of readiness. Here, the department will be assessed to have an appropriative departmental infrastructure for effectively adopting initiatives of the EHWS. With scores at this level, very few hurdles are anticipated in implementation. While constraints may arise, many of them will be unanticipated, and could not really be predicted. Notwithstanding, one’s implementation plan must also cater for contingencies.

41

TABLE 6: ACTION PLAN FOR IDENTIFIED GAPS

CATEGORY OF DEPARTMENTAL READINESS

READINESS ASSESSMENT

LEVEL

IDENTIFIED GAPS

RECOMMENDED ACTIONS (to be used for operational planning)

Commitment to EHW Management policies

Planning of the EHW Management system

Implementation and operation of the EHW Management system

EHW Management system evaluation, corrective and preventive action

EHW Management review